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Abstract
Objectives To determine the injury incidence and characteristics for elite, male, artistic USA gymnasts during gymnastics competitions, held in the USA, from 2008 to 2018.
Methods Injury documentation performed by lead physician and certified athletic trainers at elite junior and senior USA Gymnastics competitions from 2008 to 2018 were reviewed and compiled into an excel database. Injury incidence was computed per 1000 registered gymnasts by competition setting as well as injury location, type, cause, severity, and setting.
Results From 2008 to 2018, 180 injuries were reported in a total of 2102 gymnasts with injury incidence of 85.6 per 1000 gymnasts (95% CI 73.4 to 97.8). The most common injury site was at the ankle (16.7 per 1000 gymnasts, 95% CI 10.9 to 22.4), and muscle strain/rupture/tear was the most common type of injury (28.5 per 1000 gymnasts, 95% CI 21.2 to 35.9). The most common cause was contact with surface (56.1 per 1000 gymnasts, 95% CI 46.1 to 66.2), and the event where most injuries were sustained was the vault (21.9 per 1000 gymnasts, 95% CI 15.4 to 28.4). Incidence of time loss injuries was 38.5 per 1000 gymnasts (95% CI 30.1 to 47.0). Injury incidence was higher during competition (58.5 per 1000 gymnasts, 95% CI 48.2 to 68.8) than during training (27.1 per 1000 RG, 95% CI 19.9 to 34.3; RR 2.16, 95% CI 1.59 to 2.94, p<0.001); injury incidence was greater at Olympic Trials (RR 3.23, 95% CI 1.24 to 8.47, p=0.017) than at National Qualifier meets. We report concussion incidence in gymnastics (5.7 per 1000 gymnasts, 95% CI 2.3 to 9.2).
Conclusions This is the largest injury study to date for male artistic gymnasts (180 injuries, 2102 gymnasts, 11 years).
- gymnastics
- injuries
- concussion
- injury prevention
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Introduction
The sport of gymnastics is a widely popular Olympic sport.1 In the USA today, more than 200 000 athletes and non-athlete professionals (ie, coaches/judges/owners/administrators/etc) are members of USA Gymnastics, the national governing body for the sport of gymnastics. USA Gymnastics sanctions approximately 4000 competitions and events per year. [https://www.usagym.org/pages/aboutus/pages/about_usag]
USA Gymnastics includes multiple disciplines (ie, artistic, rhythmic, acrobatic, trampoline and tumbling, parkour and gymnastics for all) and skill levels. Men’s artistic gymnastics, specifically, includes six events: floor exercise, pommel horse, rings, vault, parallel bars and horizontal bar. This demands a variety of high-impact and dynamic skills, which create a wide exposure to possible injury locations and types.2 Gymnasts competing at the top level (ie, Elite) perform the highest difficulty skills.
A 2018 literature review by Hart et al, looking at gymnastics injury risk broadly (including male/female, artistic/nonartistic, all levels), cites a range of 1.08–50.3 injuries per 1000 hours of exposure.3 The published literature contains limited data on injury risk for gymnastics overall and the majority of available studies are narrowly focused on female and/or artistic gymnastics.3 4 There is a dearth of data specific to men’s artistic gymnastics.4
Previous gymnastics studies and reviews have noted greater injury rates in more high-stakes situations—injury during competition.3–6 We considered the setting (precompetition training vs competition) and type of competition (eg, lower stakes annual meets, like the Winter Cup Challenge vs higher stakes infrequent meets, like Olympic Trials) when we analysed injury rates. We aimed to determine the incidence and characteristics of injuries in elite, male, artistic USA gymnastics and to compare incidence across competition settings and years of competition.
Methods
A retrospective analysis of injury documentation from elite junior and senior USA Gymnastics competitions, from 2008 to 2018, was reviewed. Injuries were identified using the International Olympic Committee (IOC) injury surveillance approach to multisport events as a model.7 After compilation of data into an excel database, injury and illness incidence was computed per 1000 registered gymnasts and injuries were further analysed by location, type, cause, severity and setting.
Study population and gymnastic meets
This was a retrospective analysis using a study population of male, senior and junior, elite level gymnasts that were registered to participate in the studied gymnastic meets: the Winter Cup Challenge annually from years 2008 to 2018, US Artistic Gymnastics Championships annually from 2008 to 2018, US Olympic Trials in 2008, 2012 and 2016, and the National Qualifier in 2010, 2013 and 2014 (gymnasts not meeting these criteria were excluded). USA Gymnastics junior and senior elite levels are composed of gymnasts of age 12–18 years old and 16 years old or greater, respectively, competing under international rules.
Definition of injury and illness
The IOC approach to injury surveillance in multisport events was used as a model for our study.7 We defined an injury as any musculoskeletal complaint or concussion newly incurred (excluding pre-existing and not fully rehabilitated injuries) during competition or training, during the studied gymnastics meets that received medical attention regardless of the consequences with respect to absence from competition or training.7 We defined a medical illness as a physical or psychological complaint or manifestation by an athlete not related to a musculoskeletal injury, regardless of its consequences with respect to impairments in connection with competition or training.8 Medical illnesses were excluded from the injury data but were included in our study as they receive medical attention, use medical resources and have an impact on safe participation and time loss of the athlete. In cases where a single incident caused multiple injury types or affected multiple body parts, all diagnoses were included as independent injuries.
Injury characteristics
Injury reports were reviewed and the diagnoses were categorised by injury location, type, event, cause, severity and whether the injury occurred during competition or training.7 8 The details of each category are further characterised in online supplemental tables 1 and 2. Incomplete data were categorised as ‘missing value’ and was included in the data set. To determine the injury severity, the clinical documentation and competition results were reviewed to determine if a gymnast returned to participation following the injury. Illnesses were categorised by organ system, region and aetiology as defined by 2020 IOC consensus statement.9
Supplemental material
Supplemental material
Injury and illness documentation and data collection
Standardised USA Gymnastics Injury/Illness Evaluation and Sanctioned Event Incident Report forms were used during all studied meets. These evaluation forms were developed and used by USA Gymnastics medical staff. An example of each form is presented in figure 1.
Injury documentation—USA Gymnastics Sanctioned Event Insurance Incident Report Form (left) and Injury/Illness Evaluation Form (right).
At each studied gymnastic meet, medical personnel included physicians and certified athletic trainers, who were present at all training and competition sessions, and evaluated all injuries, at the time of injury. The primary author was the lead physician at all studied competitions and confirmed all injuries at the time of evaluation, through clinical examination and onsite imaging. The primary author compiled all documentation at the completion of each corresponding event.
Data analysis
Data entry was performed using Microsoft Excel and any discrepancies or duplicates were clarified by primary author. Injury incidence was calculated as the number of injuries per 1000 registered gymnasts. The list of registered gymnasts at each meet was retrieved from the USA Gymnastics website. [https://www.usagym.org]
Injury incidence rates with 95% CIs were computed and presented per 1000 registered athletes by competition setting (meet type, competition vs training, year), and by injury characteristics (location, type, cause, event, severity). This measure of incidence is consistent with reporting from previous injury studies.5 7 8 10–12
To compare injury incidence across competition settings, relative risks with 95% CIs were computed directly from cross-tabulations with p values estimated by Z-test.13 14 The lowest injury incidence category selected as the reference group for comparisons. χ2 test for linear trends were computed to examine trends in incidence across years. As hypothesis tests were conducted for five comparisons in total, p values <0.01 (applying Bonferroni correction for a family-wide type I error rate of 0.05) were considered statistically significant. The characteristics of injuries were presented as percentage of all observed injuries with a given characteristic. Medical illnesses were analysed and reported separately per recommendations of the IOC consensus statement on methods for recording and reporting of epidemiological data in sport.9 All analyses were conducted using Microsoft Excel.
Confidentiality and ethical approval
The initial evaluation and documentation were collected during the event at the time of injury, under consent-to-treat event medical coverage guidelines. At the time of injury evaluation, research was not intended and therefore athletes were not informed that their clinical data would be used for research purposes. Following the individual events, physical copies of injury reports were kept by the primary author. During subsequent retrospective analysis, athlete information was anonymised when entered into the statistical software. It was not applicable to involve patients or the public in the design, conduct, reporting or dissemination plans of our research.
Results
Injury and illness incidence
Across all settings, 180 injuries were observed in 2102 registered gymnasts. Overall injury incidence was 85.6 per 1000 RG (95% CI 73.4 to 97.8; see table 1). In addition to the 180 injuries, there were nine medical illnesses documented with illness incidence of 4.3 per 1000 RG (95% CI 1.3 to 7.3). Illness aetiology was infection for all nine. By organ system, four respiratory, three gastrointestinal and two dermatological illnesses occurred.
Injuries by competition setting
Injuries by location, type, cause, event and severity
Incidence rates by categories of injuries are presented in table 2. The categories of injuries with the highest incidence rates are in the lower limbs (42.8 per 1000 RG, 95% CI 33.9 to 51.7), include muscle strain, rupture or tear (28.5 per 1000 RG, 95% CI 21.2 to 35.9) or ligament sprain (20.5 per 1000 RG, 95% CI 14.2 to 26.7), occur during the vault event (21.9 per 1000 RG, 95% CI 15.4 to 28.4) and result in no time loss (51.4 per 1000 RG, 95% CI 41.7 to 61.1). Incidence of injuries resulting in at least some time loss (partial + full) was 38.5 per 1000 RG (95% CI 30.1 to 47.0). Concussion incidence was 5.7 per 1000 RG (95% CI 2.3 to 9.2, table 3). A detailed breakdown of injury types by location is presented in online supplemental table 3.
Supplemental material
Injuries by location, type, cause, event and severity
Concussion injury characteristics
Injuries by competition setting
Incidence was lowest in national qualifier meets (40.3 per 1000 RG, 95% CI 13.8 to 66.8), and higher at USA National Championship meets (RR 2.77, 95% CI 1.47 to 5.23], p=0.002) and at the Olympic Trials (RR3.23, 95% CI 1.24 to 8.47, p=0.017), although p value is without significance for Olympic Trials. Injury incidence was significantly higher during competition (58.5 per 1000 RG, 95% CI 48.2 to 68.8) vs training (27.1 per 1000 RG, 95% CI 19.9 to 34.3; RR 2.16, 95% CI 1.59 to 2.94, p<0.001). Within meets that occur annually (Winter Cup and USA National Championships), there was marginal variation between years (X 2 (10, n=1808)=19.6, p=0.033), ranging from 45.5 per 1000 RG (95% CI 9.3 to 81.6) in 2018 to 143.79 per 1000 RG (95% CI 84.9 to 202.7) in 2015. There was no significant linear trend suggesting increases or decreases in incidence across years (X 2 (1, n=1808)=0.1, p=0.81).
Discussion
This is the largest injury study to date for men’s artistic gymnastics (180 injuries, 2102 gymnasts, 28 meets over 11 years).
Overall injury incidence
Injury incidence for male, elite level, artistic gymnastics during the studied gymnastics meets was 86 per 1000 registered gymnasts (95% CI 73 to 98). This is similar to incidence rates of 83 (95% CI 51 to 115) injuries per 1000 male RG that competed at the 2008, 2012 and 2016 Olympic Games.5
Injury characteristics
Lower extremity injuries were more common than upper extremity injuries
Prior studies characterising artistic gymnastics injuries describe a higher rate of lower extremity sprains and strains.3–5 15–18 Our study showed ankle sprain as the most frequent injury (11%). By cross-referencing injury type by location, we could determine the rates of specific diagnoses (online supplemental table 3).
Previous data on male injury rates, which included both incidence and prevalence data, suggest a higher rate of upper extremity injury.3 4 19 Events, such as the rings, parallel bars, pommel horse and horizontal bar, are unique to men’s artistic gymnastics and place a significant demand on the upper body. Our incidence data, however, is comparable to female artistic gymnastics showing that lower extremity injuries occur at higher rates.
Injury incidence in vault and floor exercise were comparable
There was not a significant difference between injury incidence on vault (95% CI 15 to 28) vs floor (95% CI 12 to 24), with a higher percentage of injury seen in vault. This is unique reporting with previous studies having reported floor exercise with the highest rate of injury.4
Time loss injuries
We were able to further breakdown injury rates per registered gymnasts for injuries that resulted only in time loss. The goal of this calculation was to minimise an overestimation of the injury rate. Our rate of 39 time-loss injuries per 1000 RG is a lower rate compared with the IOC data of 48 per 1000 RG for male gymnasts.5
Injury rates by year
There is concern in the sport of artistic gymnastics regarding a continually increasing injury risk as the skill level and demands continue to advance. The IOC data suggested an increased rate of injury in 2016 compared with 2008.5 Our data set shows a peak injury incidence in 2015, with a subsequent decrease in injury incidence between 2015 and 2018 (table 1). This is a hopeful trend that demands further exploration.
Injury incidence during competition versus training
We reported a higher injury incidence during competition compared with precompetition training (table 1), consistent with previous literature.3 4 6 19 In our study, 68% of injuries occurred during competition. This is consistent with the IOC data showing 67% of injuries during competition, for male, artistic gymnasts.5
Similarly, we found that injury incidence was higher during meets with higher perceived level of competition, with the highest risk during the Olympic Trials (3.2 times greater than at National Qualifier meets), followed by USA National Championships, Winter Cup Challenge, and National Qualifier. This may be due to increasing levels of higher stress and skill difficulty.
Concussion risk in men’s, elite, artistic gymnastics
Prior to this study, there has been no published data on concussion incidence in artistic gymnastics.3 Hecht et al, explained that a gymnast can sustain a concussion during gymnastics participation by hitting his or her head to the apparatus, mat or other body part.20 In our study, concussion made up 7% of injuries, an injury incidence of 5.7 injuries per 1000 RG; a higher incidence than common injuries such as fracture and ligament rupture.
Additionally, our concussion data are the reflection of how rule changes can have a positive effect on injury risk. 6 of 12 concussions were noted to involve a floor exercise skill named the Thomas (a skill that involves the gymnast landing onto their hands in a forward roll after performing one and a half back flips with a twist; table 3). After the 2016 Olympic Games, the International Gymnastics Federation (http://www.fig-gymnastics.com) banned the Thomas skill for male artistic gymnastics. Close inspection of our data reveals a cluster of seven concussions that occurred in the years 2013 and 2014 (table 3). Four of the seven concussions occurred while performing the Thomas skill. In the years 2017 and 2018, following the ban on the Thomas skill, our data reveal only one concussion event.
Strengths and limitations
Our study does include a robust number of registered gymnasts, capturing data from a consistent sampling of annual competitions across multiple years. These data are the largest injury data set for male artistic gymnasts. We used competition medical records for accurate injury reporting.
Athlete exposure is classified as injuries per 1000 registered gymnasts, consistent with other published studies.5 7 10 This method of injury reporting is consistent with the IOC approach but different than the injury reporting method of athlete exposure discussed in Campbell et al’s review.4 7 There are limitations to our calculation since it does not account for the variable participation of each registered gymnast, includes multiple injuries to the same gymnast, and has the potential clustering of injury risk within teams or demographic subgroups. Further, although the sample is reasonably large (over 2000 athletes), some injury categories are small which may lead to inflation of relative risk estimates due to sparse data bias.21 For this reason, all relative risks and 95% CIs were calculated through direct analysis of cross-tabulation rather than logistic regression (maximum likelihood estimation), and estimates with wide confidence intervals should be interpreted with caution.
During some gymnastics meets, not all gymnasts compete on every event. Additionally, this exposure definition does not take into account the number of hours each gymnast participated in pre-competition training during the week of competition. Elite, men’s, artistic gymnastics is a niche sport and therefore, in our study, identical registered gymnasts are undoubtedly counted multiple times.
This data set is a retrospective analysis that relies on event medical documentation. This documentation captures only injuries that occurred on the floor of the competition and/or training, or injuries that self-reported to the medical training room during the course of a competition window. Additionally, some medical records were incomplete regarding injury details or demographics.
Our data set is for a very specific population of elite level gymnasts. We do not know if these injury characteristics are transferable to younger non-elite level gymnastics. Additionally, the demographic information in our study is limited. More detailed demographic information would be helpful for further risk stratification.
Recommendations
Our data suggest that future work should focus on prevention programmes for ankle injuries in elite male gymnasts. Additionally, there should be continued inspection into rule changes and equipment structure to advance vault safety.
Our study confirms a high incidence of concussion in elite male gymnastics. This supports future development of concussion protocols and educational programmes for the sport of gymnastics.
Continued work should be done to ensure consistent injury definitions, validated data collection and consistent interpretation of injury severity.4 5 8 22 There is still a need for large, prospective multidisciplinary injury studies across different levels of club and elite level gymnastics.3–5
Our injury data also help inform how medical professionals provide care at gymnastics events. By understanding injury trends, such as injury location, type, event and cause, we can make adjustments in staffing and medical equipment. These data suggest ensuring proximity of medical professionals to the vault landing during competitions, and ensuring staff is prepared to appropriately treat an ankle or lower extremity injury.
In summary, our unique database of injuries provides the largest collection of male artistic injury data published to date. This study confirms a high incidence of injury in male elite artistic gymnasts, shows acute injury characteristics that are similar to those found in female artistic competitors, and provides the first glimpse of concussion incidence in this sport. This study further highlights the high risk for injury inherent within elite level gymnastics and motivates further prospective work into characterising injuries across multiple levels and disciplines in the sport of gymnastics.
What are the findings?
This is the largest injury study to date for men’s gymnastics. (180 injuries, 2102 registered gymnasts, 11 years).
This is the first study that reports concussion incidence in gymnastics. Concussion made up 7% of injuries, corresponding to an incidence of 5.7 concussions per 1000 registered gymnasts (95% CI 2.3 to 9.2).
Injury incidence for elite, men’s, artistic gymnastics was 85.6 injuries per 1000 registered gymnasts (95% CI 73.4 to 97.8).
Injury incidence was higher during competition (58.5 per 1000 RG, 95% CI 48.2 to 68.8) vs training (27.1 per 1000 RG, 95% CI 19.9 to 34.3; RR 2.16, 95% CI 1.59 to 2.94, p<0.001).
Incidence was higher at the Olympic Trials (RR 3.23, 95% CI 1.24 to 8.47, p=0.017) and USA National Championship (RR 2.77, 95% CI 1.47 to 5.23, p<0.001) compared with the National Qualifier meets
Vault had the highest injury rate (21.9 per 1000 RG, 95% CI 15.4 to 28.4) and ankle sprain was the most frequent diagnosis, comprising 11% of the injuries.
How might it impact on clinical practice in the future?
Male artistic gymnastics injury prevention should focus on ankle injuries and vault safety.
Event administration and medical staff should prepare for higher frequencies of injury during higher levels of competition.
Medical providers should be prepared to provide care for concussions in men’s artistic gymnastics.
Acknowledgments
We would like to acknowledge USA Gymnastics for their support and the medical professionals who have provided excellent care for these injured athletes across many competitions.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
DWK and ASN are joint first authors.
Contributors DWK: Substantial contributions to the conception and design of the study, collection and interpretation of data, drafting, writing, and revision of the manuscript and final approval of the version to be published. ASN: Substantial contributions to the conception and design of the study, analysis and interpretation of data, drafting, writing and revision of the manuscript, and final approval of the version to be published. JB: Substantial contributions to analysis and interpretation of the data and revision of the manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent for publication Not required.
Ethics approval The study was approved by Memorial Care Research Administration Human Research Protections Programme.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement Data are available on reasonable request. Deidentified injury data that underlie the results reported in this article are available on reasonable request to primary author’s email address with researchers who provide a methodologically sound proposal and can be used to achieve the aims in the approved proposal. Data will be available immediately after publication with no end date.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.